Lect 1 physical assessment acute care nursing program 2005
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Lect 1 physical assessment acute care nursing program 2005
- 1. Physical Assessment Acute Care Nursing Program 2005
- 2. Outline Assessment Process Respiratory Assessment Cardiac Assessment Neurological Assessment Abdominal Assessment Neurovascular Assessment
- 3. Assessment Process Inspection Palpation Percussion Auscultation Gather information – base line Record trends
- 4. Respiratory Assessment Inspection Palpation Percussion Auscultation
- 5. Respiratory Assessment Inspection General appearance, colour Scaring Symmetry Shape Position of trachea Work of breathing Rate Rhythm Cough – productive?
- 6. Respiratory Assessment Palpation Chest excursion Tactile and vocal fremitus
- 8. Respiratory Assessment Percussion Normal – resonant, hollow sound Solid - dull Percussion is done in the intercostal spaces Percussion is done both on the posterior chest and lateral chest
- 10. Respiratory Assessment Auscultation Systematic approach Note adventitious (extra) Crackles Wheeze Friction rub
- 12. Cardiac Assessment Inspection Palpation (Percussion) Auscultation
- 13. Cardiac Assessment Inspection JVP Oedema Colour
- 14. Cardiac Assessment Palpation Pulse Oedema Capillary refill Blood pressure
- 15. Cardiac Assessment Auscultation Normal S1 S2 Abnormal S2 split S3 S4
- 18. Neurological Assessment Glasgow Coma Scale Cranial Nerves
- 19. Glasgow Coma Scale Assess neurological status Assessment of best response Eyes Verbal Motor
- 20. Glasgow Coma Scale Scor e Best Eye Best Verbal Best Motor 6 ----------- ----------- Obeys 5 ---------- Orientated Localises pain 4 Spontaneous Confused Withdraws 3 To speech Inappropriate Flexion 2 To Pain Incomprehensible Extension 1 None None None
- 21. Cranial Nerves 12 cranial nerves 3rd – 12th within brainstem (Midbrain, Pons, Medulla)
- 22. Cranial Nerve I Olfactory Function: Sensory Smell Assessment: Recognition of odor
- 23. Cranial Nerve II Optic Function: Sensory Information from the retina Assessment: Visual acuity
- 24. Cranial Nerve III Oculomotor Function: Motor Four of the six extra-ocular muscles Assessment: Response to light Moves eye Elevates upper eyelid
- 25. Cranial Nerve IV Trochlear Function: Motor Controls the oblique eye muscle Assessment: Moves eye right, left, up and down
- 26. Cranial Nerve V Trigeminal Function: Mixed Three sensory Corneal Reflex One motor Assessment: Normal facial sensation Blinks Clenches teeth
- 27. Cranial Nerve VI Abducens Function: Motor Lateral rectus muscle of eye Assessment: Moves eye laterally
- 28. Cranial Nerve VII Facial Function: Mixed Sensory Tongue Motor Eyelids Assessment: Elevates eyebrows Puffs checks Recognizes tastes
- 29. Cranial Nerve VIII Vestibulocochlear Function: Sensory Hearing Assessment: Whisper in each ear
- 30. Cranial Nerve IX Glossopharyngeal Function: Mixed Sensory Taste buds Motor Gag reflex Assessment: Taste testing Test gag
- 31. Cranial Nerve X Vagus Function: Mixed Motor branches to the pharyngeal and laryngeal muscles Viscera of the thorax and abdomen Assessment: Same as IX
- 32. Cranial Nerve XI Accessory Function: Motor Innervates the sternocleidomastoid and trapezius muscles Assessment: Shrugs shoulders
- 33. Cranial Nerve XII Hypoglossal Function: Motor Tongue muscles Assessment: Sticks out tongue
- 34. Abdominal Assessment Inspection Auscultation Percussion Palpation
- 37. Abdominal Assessment Inspection Asymmetry Engorged veins Intestinal movements Lesions Scars Swelling
- 39. Abdominal Assessment Auscultation Systematic Bowel sounds
- 40. Abdominal Assessment Percussion All four quadrants Tympanic- air filled structures Dull – solid structures Bowel Liver Bladder
- 43. Abdominal Assessment Palpation Light and Deep Tenderness, guarding, rigidity Define organs Kehr’s sign McBurney’s point Murphy’s sign
- 44. Neurovascular Assessment Colour Temperature Capillary Refill Peripheral Pulses Swelling Movement Sensation
- 45. References A Practical guide to clinical assessment http://medicine.ucsd.edu/clinicalmed/ Smith SF, Duell DJ & Martin BC, 2005, Clinical Nursing Skills, Prentice Hall, New Jersey.
Editor's Notes
- Inspection: Observe the patient of skin colour and texture; check for lesions, scars of hair disruption Palpation: Information by using hands and finger to palpate. A light or deep palpation depending on the area being palpated. Used to assess organ position, size and consistency, fluid accumulation, pain and masses. Percussion: Produces sound waves by using the fingers as a hammer. Vibration is produced by the impact of the fingers striking against underlying tissue. Sound or tone is usually determined by the body area or organ percussed. Auscultation: Listening using a stethoscope. Place stethoscope on bare skin to listen for the characteristics of sound waves. The bell of the stethoscope is used to detect low-pitch sounds, the diaphragm to detect high-pitched sounds. Notice vibrations in intensity, pitch, duration and quality.
- Pulse – pulse deficit listen to apex and feel radial – if there is a difference this indicates a pulse deficit
- S1 – tricuspid and mitral valve closure S2 – pulmonic and aortic valve closure
- S2 split – A2 = aortic valve closure, P2 = pulmonic valve closure. On inspiration, venous return to the heart is impeded and pulmonic valve closure is delayed resulting in a split sound. Can be normal in some people. Get patient to hold breath to hear this better S3 – left ventricular failure: and is caused by blood from the left atrium slamming into an already overfilled ventricle during early diastolic filling S4 - left ventricular hypertrophy: blood trying to enter a stiff, non-compliant left ventricle during atrial contraction
- Recognition of an odour such as coffee or toothpaste
- Ability to read newsprint
- Motor nerve: controls four out of the six extra-ocular muscles, raise eyelids and controls the constrictor pupillar and ciliary muscles of the eyeball.
- Assessment: Clenches teeth with no lateral jaw deviation
- Recognises tastes such as sugar salt
- Ability to stick tongue out in a midline without deviation
- Cullen's sign – bluish colour around the umbilicus seen in hemorrhagic pancreases Grey turner’s sign – bruising in the flanks associated with retroperitoneal bleeding.
- Caput Medusae – head of medusa a mythical snake-haired person. Associated with
- Start in (L) lilac fossa region Bowel sounds – timing, frequency, etc… Renal arteries – bruits, abnormal pathological flow of blood resulting in a swishing sound or murmur. Note timings such as, occurrence with other cycles and location. All are specific
- Liver, start high on ribs and work down Bladder – only when full, otherwise is small within pelvis
- Liver, start high on ribs and work down Bladder – only when full, otherwise is small within pelvis
- Liver, start high on ribs and work down Bladder – only when full, otherwise is small within pelvis
- Kehr’s sign – referred pain to shoulder in splenic injury (occurs in approx 50% of cases) McBuney’s point – located 1/3 distacnce from the anterior superior iliac spine to the umbilicus. Tenderness associated with appendicitis Murphy's sign – on inspiration, pain associated with palpation of the RUQ, indicative of choecystitis.